Leave of Absence Request
Student Information
Name
*
First Name
Last Name
L#
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Academic Major
Current Academic Level
*
Undergraduate
Graduate
Other
Requested Start Date of Leave:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Anticipated Return Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Term of Absence
*
Please Select
Fall 2026
Spring 2027
Fall 2027
Spring 2028
Fall 2028
Spring 2029
Fall 2029
Spring 2030
Fall 2030
Spring 2031
Fall 2031
Spring 2032
Fall 2032
Spring 2033
Fall 2033
Spring 2034
Fall 2034
Spring 2035
Fall 2035
Spring 2036
Fall 2036
Reason for requested leave
*
Personal
Family
Medical
Financial
Opportunity pursuit (internship, etc.)
Other
Please provide a detailed explanation for your Leave of Absence request. You are encouraged to provide any documentation to support your Leave of Absence (Financial Aid may require additional documentation based on federal and state aid).
*
Upload documentation here
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SPECIAL STATUS VERIFICATION
The following students must consult with the designated campus representative for approval.
Are you a student-athlete?
*
Yes
No
Are you a veteran or veteran-dependent student?
*
Yes
No
Are you an international student with an F-1 Visa?
*
Yes
No
Do you currently reside in campus housing?
*
Yes
No
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ACKNOWLEDGMENTS
I understand that a Leave of Absence is valid for one semester (Fall or Spring) after the date of approval.
*
I understand that after one semester (Fall or Spring), if I have not re-enrolled, I will be reported as withdrawn and will be required to reapply for admission prior to returning.
*
I understand that a Leave of Absence can only be granted for one semester at a time and a Leave of Absence may only be taken twice within a six year period.
*
I understand that if I have Federal Title IV financial aid, my Leave of Absence cannot exceed one semester (Fall or Spring) in any 12-month period.
*
I understand that Lipscomb University will not approve or recognize transfer credits for any courses that I take at another institution while on a Leave of Absence.
*
I understand that a Leave of Absence may disrupt my regular schedule of degree plans and may extend the length of time it takes to complete my degree.
*
I understand that to return from a Leave of Absence, I must contact the Academic Success Center at academicsuccesscenter@lipscomb.edu at least three weeks prior to the start of the term or semester for which I desire to return.
*
I understand that upon return, I must meet with representatives from Financial Aid/Business Office, the Student Care Coordinator, and an Academic Success Coach as part of my re-entry requirements.
*
I understand that I must have satisfied all financial obligations on my account prior to re-enrolling.
*
Submit
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